Posted tagged ‘otitis media’

Good things come in small packages. A short, sweet letter to the editor in the November, 2016 edition of JAMA Pediatrics confirms that parents can tell whether their children are getting over an ear infection, with no doctor exam required.

The letter, from four Finnish physicians, is about a page long. It summarizes a small part of their data from a much larger study on the treatment of ear infections. In the letter, they’re only looking at 160 children, age 6 months to 3 years, who were initially treated for an ear infection without any antibiotics. Current guidelines from the US and many other countries do support treating less-severe ear infections with pain relievers only, waiting on antibiotics. But these guidelines suggest that if children with ear infections aren’t given antibiotics, they need to be followed closely and re-examined to make sure they’re really getting better. These authors asked, is that really necessary?

The 160 children were all reexamined for this study, and parents were also asked questions about whether they thought their children were improving, getting worse, or staying about the same. It turns out that among the children whose parents thought were getting better, only a very small number had worsening ear exams (less than 3%). Compare that with children thought to be getting worse – about 30% had worsening findings on their ear exams. Keep in mind that these were all children who did not receive any antibiotics. Presumably, if they had, even fewer of them would have gotten worse.

Parents, not surprisingly, were pretty good at judging whether their children were getting better. So good that based on these numbers, a repeat exam to make sure ear infections were clearing was probably unnecessary!

Caveats: I’d be a little more cautious with children at risk for prolonged ear infections or persistent fluid behind the ears. Children with a history of difficult-to-treat ear infections should get a repeat exam, as should kids with hearing problems or developmental language delays—it’s crucial that those children get over their infections completely. But for the majority of children with ordinary ear infections that seem to be getting better, it may be reasonable to wait until their next check up to look at those ears again. Most of the time, parents’ judgment is just as good as a repeat ear exam.

One of my sons recently developed an ear infection, and various people have suggested sticking a clove of garlic in his ear, or garlic ear drops. Of course, we took him to the doctor who prescribed Amoxicillin, which worked quickly and well.

I have a hard time believing that garlic is a natural antibiotic that could be substituted for actual antibiotics. I could believe that garlic has antibiotic properties, but that shoving garlic in your ear (besides just being a bad idea to stick things in one’s ear) would be a poor way to access them.

So…does garlic have an antibiotic properties? Could it be used (in some form, drops into/onto the infection or eating it) to cure an infection?

First: does garlic have antibiotic properties? Can it kill or suppress the growth of bacteria? It makes sense that it would. Vegetables and other things that live and grow have evolved elaborate mechanisms to fight back against anything that wants to kill them. Armadillos have those hard shells, poison dart frogs have poison, and manatees have – well, I don’t know what they have, but considering that their natural predator is the speedboat, what they probably need is some kind of rocket harpoon. Plants, too, have elaborate defenses, like spikes on cactuses, or toxic chemicals that prevent them from getting eaten or infected with parasites and bacteria. Yes, your vegetables are literally loaded with toxins, including antibiotics. Elaborate chemical studies that have confirmed this – multiple substances in garlic do fight bacteria.

But does that mean garlic, placed in the ear, can help fight off an ear infection? Nope, it can’t. It’s a simple matter of anatomy. An “ear infection” – more properly called an “otitis media” – is an infection in the middle ear cavity, behind your eardrum. Unless you poke a garlic clove in far enough to pop the drum and push on through (do NOT do that), garlic placed in the ear cannot get to the site of the infection. Putting garlic in your ear to combat an ear infection is like putting oil next to your car engine for lubrication, or putting food near your mouth to eat it. To fight an infection, an antibiotic needs to be where the bacteria are. And an ear infection is internal, on the other side of your eardrum, where garlic or garlic oil pushed into the ear cannot reach.

But, and here’s the rub: if you put garlic in your child’s ear during an ear infection, will he get better? Probably yes. That’s because most ear infections get better on their own, without any antibiotic at all. You can stick garlic in the ear, or margarine, or a banana, or skinny Aunt Lulu – any of those might seem to work, but none of them will make any difference at all. Still, you’ll see it all over The Internets: I put garlic in an ear, and the infection got better, so yeah. Sorry. That doesn’t prove anything.

Side note: there’s another cause of ear pain, called a swimmer’s ear (or “otitis externa”). This is an infection of the ear canal itself, outside of the eardrum. Hypothetically garlic placed in the ear could reach that surface. But I wouldn’t recommend it. Swimmer’s ears hurt, and hurt bad, and pressing a garlic clove in there may make it hurt more.

Garlic steeped in olive oil sounds like a great spread for crostini, and it might keep vampires away. But it’s not going to help anyone with an ear infection.

The AmericanAcademy Otolaryngology – Head and Neck Surgery (AAO-HNS, often abbreviated “ENTs”) has come out with their official, evidence-based guide to one of the most common medical procedures in children: tympanostomy tubes, or “ear tubes”. It’s long, it’s detailed, and it’s well-referenced, and it ought to help guide ENTs, family docs, and pediatricians to help families make good decisions about who needs tubes, when they ought to be done, and how to take care of them.

The document includes solid background info on the health care burden of ear infections, and the risks and benefits of tubes. What I’m going to concentrate on here is the twelve “action” statements that they’ve come up with to guide health care decisions. All of these I’m paraphrasing from the statement—take a look there for references supporting these statements.

The first five statements are about children with what’s called “OME”, for “otitis media with effusion.” This is when there’s clear, uninfected fluid behind the eardrum. OME does not cause pain or fever or really other symptoms, though may be associated with some hearing loss. OME should not be treated with antibiotics—it is not an infection, and antibiotics will not help. It’s typically called “fluid in the ear” or “fluid behind the eardrum.”

1. Do not place tubes for uninfected fluid behind the eardrums (OME) of less than three months duration. Uninfected fluid just sits there and causes minimal symptoms (perhaps some blunted hearing), and it can be safely observed for at least 3 or more months before surgical intervention is even considered.

2. If fluid (OME) persists > 3 months, do a hearing test prior to surgery, or when surgery is considered. The reason to “fix” OME is to correct a possible hearing deficit; if there is no deficit, tubes are not generally needed. You have to check, first.

4. If there is fluid (OME) > 3 months plus other symptoms like school issues, balance problems, ear discomfort, or “reduced quality of life”, tubes can be considered as an option. This is not a recommendation—just an “option”, because there is very little evidence that tubes will fix these problems.

5. If fluid (OME) lasts > 3 months, it ought to be monitored at regular intervals to make sure hearing remains normal and that there are no other medical problems being caused by the fluid.

The next three statements are about “AOM”, or acute otitis media, defined by infected fluid behind the eardrum. It’s red, it’s bulging and distorted, and it causes ear pain and other symptoms. This is what’s commonly called an “ear infection”.

The statement defines “recurrent AOM” as 3 or more proven ear infections in the last 6 months, or 4 in the last 12 months (including at least 1 in the last 6 months.)

6. Clinicians should not place tubes for recurrent AOM if there is not fluid behind the ear at the time of the assessment. This is a little bit of a slap at pediatricians and the rest of us who diagnose ear infections—basically, it says that the ear specialist has to see for themselves that there is at least one infection before doing surgery. I agree with this. Ear infections can be tricky to see and are frequently over-diagnosed. If Junior isn’t really having ear infections, surgery is not going to help.

7. Ear tubes (in both ears) should be offered for recurrent AOM who have middle ear disease at the time of the evaluation. Note that “offer” is not a very strong recommendation—there is limited evidence that tubes help prevent AOM, and what evidence there is shows only a modest effect.

The next two statements refer to children who have special medical needs:

8. Clinicians ought to consider the big picture—including what children are at risk for further ear infections or developmental challenges related to hearing loss. Children with anatomic issues (eg, cleft lip), or baseline cognitive, developmental, or behavioral issues are at higher risk for complications from AOM, so may benefit from more-aggressive therapy.

9. In children “at risk” per statement 8, consider tubes when fluid lasts for three months or longer.

And, last, there are three miscellaneous statements:

10. Clinicians should teach families about tubes, especially about the expected duration of function, after-care, and potential for complications.

11. If there is drainage from tubes, it ought to be initially treated with eardrops instead of oral antibiotics.

12. Children with tubes should not be routinely discouraged from water sports, and need no routine ways to prevent water from getting into their ears. That means no earplugs, no headbands—just go swim and enjoy yourself.

So: a lot of information. The most important points are about fluid behind the eardrum. If it is uninfected, it can safely be monitored for at least three months before even considering tubes; even then, tubes really only should be pursued if there is hearing loss or a high probability of complications. If there is infected fluid behind the eardrums, tubes should only be considered if there are documented recurrent episodes, at least three in the last six months. And: ENTs and pediatricians ought to stop encouraging earplugs and water restrictions, because those measures do not help.

For those of you interested in the details, the full report is quite detailed and referenced—and can probably teach most physicians quite a bit about the best way to manage common ear problems. Tubes can help, sometimes, but they’re not always needed, and ought to be used only when they’re likely to help.

“My toddler keeps getting ear infections. There’s got to be a way to help with this. What can we do to prevent them?”

It’s frustrating, I know. Ear infections—doctors call them “otitis media”, because we need fancy-pants names for ordinary things—are very common, and account more antibiotic prescriptions than any other pediatric infection. Why do kids get so many of them?

If you stick your finger in your ear, it won’t go very far. Which is probably a good thing. If your finger were oddly thin and pointy, though, you’d be able to reach down your own ear canal to touch your eardrum (doctor-speak: “tympanic membrane”), a little flimsy sheet of tissue that closes off the end of the outer ear parts and separates the ear canal from the middle ear. Ordinarily, on the other side of the eardrum is a small, open, air-filled space through which sound waves can be transmitted with the help of three interlocking little bones. The important thing to remember is that this middle ear cavity is sealed off on all sides, and is supposed to be filled with ordinary air. There is a little drainage tube on the bottom which can allow tiny droplets of normal mucus to drain out of the middle ear into the nose. All of this works pretty well, most of the time.

Until the drainage tube (doctor-talk, “Eustacian tube” or “Auditory tube”) gets clogged up. Then the middle ear space fills with nice warm mucus. That sits there. And you can guess what happens: bacteria love warm, stagnant mucus. Party time = infection in the middle ear = Mommy, my ear hurts!

What causes congestion that clogs up the drainage tube? Usually, a common cold virus. Junior gets the dreaded yuck, gets all snotty, the tube clogs, and normal mucus can’t drain. That leads to ear infections.

Little kids get far more ear infections than adults. They get far more colds, especially if they’re enrolled in group care. They’re not very good at blowing their little noses and clearing out mucus. But most importantly, that drainage tube of theirs is oriented horizontally, and it’s thin—the net effect being, it doesn’t drain well. They’ve basically got lousy gutters, and the mucus builds up behind them, especially when there’s a lot of snot around.

Ear infections do run in families, probably because some families tend to have even worse middle ear anatomy that predisposes to more infections. Parental smoking is also a big-time contributor to ear infections, because that contributes to chronic congestion and poor drainage. Sometimes, chronic nasal allergy causes nasal congestion, poor drainage, and at least some ear infections. But by far, the biggest contributor to ear infections are ordinary common cold viruses. In fact, during an ordinary cold young children will develop an ear infection about half of the time.

So what can be done to prevent ear infections? The only really practical strategies are to try to prevent the spread of cold viruses:

In addition, try to avoid second-hand smoke, and make sure that your children are up-to-date on their immunizations. Though there is no one immunization that will prevent all or even most ear infections, some infections can be prevented by making sure that your child has had the pneumococcal conjugate and influenza vaccines.

Related posts:

Weekend ear pain action plan—you do NOT have to rush to the ER, but you ought to help your child feel better when there’s a suspected ear infection

“I can just tell he has an ear infection! Can’t you just call in an antibiotic?”

I don’t want kids to suffer, and I don’t want kids having to go to an ER or busy after-hours place on the weekend. (In Atlanta, parents have a great after-hours alternative—kids can see a real pediatrician after hours!) Why not just call in weekend antibiotics without seeing the child? If a parent thinks their toddler has an ear infection, how likely is it that they’re right?

Researchers in Finland tried to find out. In a 2010 study, they reported their findings based on 469 children over a 2 year period who were brought to a clinic because of parental concerns of a possible ear infection. The children were all aged 6 – 35 months. Prior to their exams, parents recorded the degree of ear pain, irritability, crying, restless sleep, fevers, and many other symptoms. Examinations were performed with state-of-the-art equipment, and videos of the ear exams were reviewed by an ENT specialist to confirm the diagnoses.

It turned out that none of the symptoms could reliably differentiate children with ear infections from children whose ears were normal. Not pain, not height of fever, not how the children were acting. Parents who reported these symptoms were just as likely to have a child with or without a real ear infection. Ear rubbing was actually more common in kids who did not have an ear infection.

The only reliable way to tell if a child has an ear infection is to look at the eardrum. Even then, it’s not always easy. Sometimes there’s wax, and sometimes, even for me, children squirm and yell. Unless you get a good exam, there is just no way to know. And it is important to know, before you start antibiotics– if you’re going to use antibiotics at all. Since many ear infections will improve without antibiotics, unless a child seems really miserable it’s often best to wait a few days, especially if it’s a weekend. An ear infection that got better on its own didn’t need to see the doctor, anyway!

So: if your child seems to have an ear infection on the weekend, do things to help him feel better. A gentle heating pad or a dose of ibuprofen or acetaminophen will provide quick relief. Emergency, weekend care is really only needed if your child remains miserable even after pain medication. Starting antibiotics without a sure diagnosis is like flipping a coin—you may be doing more harm than good.

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For November, I’m concentrating my writing chops on National Novel Writing Month. Fun! So I’m re-running revised versions of some classic posts. And by classic, I mean “old.” This one was originally from April, 2008. Enjoy!

“What is a reasonable amount of ear infections a child should have in a year’s time span before parents should see an ENT or ask their pediatrician about tubes?”

There isn’t a one-size-fits-all answer, but I can tell you there are things that you and your doctor should look at that will influence this decision.

Factors that would encourage me to refer for tubes sooner:

Younger child. A child who’s six months old and has already had four ear infections is already in trouble.

Ear infections that always occur in both ears simultaneously. These affect hearing more.

Ear infections that need more than one course of antibiotics to cure.

Ear infections in a child with hearing problems or speech delays.

A child who has multiple antibiotic allergies, making ear infections harder to treat.

Ear infections that are occurring at the beginning of the winter. You do expect more ear infections through the cold season, so if you know you’re heading into a time with more ear infections, you should consider tubes more seriously.

Factors that lead me to watch-and-wait longer include many things that are the opposite of the above: an older child, or a child who only has one ear infected at a time, or a child who quickly responds to antibiotics. If it’s already the end of winter, I’m often temped to wait to see if ear infections continue in the warmer months before referring.

If you want to start with a number, I’d say that more than 5 ear infections a year is too many, and most children who are having this many ought to be at least considering visiting the ENT for tubes. The absolute number that means “tubes are necessary” depends on your child’s individual circumstances.

If your child is heading for “too many” ear infections, consider some other ways to prevent them. Ask yourself:

Can I take my child out of group care?

Is my child fully vaccinated (some vaccines protect against at least some ear infections, though not nearly 100%)

Is my child exposed to second-hand smoke?

Does my child have chronic nasal allergies that haven’t been treated?

Some kids are prone to ear infections, and sometimes tubes really are the best way to get off the one-antibiotic-after-another train. Review your child’s specific history with your pediatrician to see if it’s time to head to the ENT.

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